PsychotherapyForWomen.com  Vicki Bonnell, LCSW  vickibonnell2@gmail.com

PATIENT INTAKE FORM 2

Patient Name ____________________________________

Current Symptoms/Problem Checklist: Please check all symptoms

( ) Depression ( ) Racing thoughts ( ) Anxiety /Panic ( ) Substance abuse

( ) Unable to enjoy activities ( ) Impulsivity ( ) Excessive worry ( ) Family Issues

( ) Sleep disturbance ( ) Increased risky behavior ( ) Avoidance ( ) Legal Issues

( ) Loss of interest ( ) Increase/Decreased libido ( ) Hallucinations ( ) Loss/Bereavement

( ) Concentration/Memory ( ) Decrease need for sleep ( ) Suspiciousness ( ) Pain issues

( ) Change in appetite ( ) Excessive energy ( ) Excessive Guilt ( ) Work/School problems

( ) Increased irritability ( )Trauma/Abuse ( ) Crying spells ( ) Self Body Image Issues

( ) Isolation/ Withdrawal ( ) Frustration Tolerance ( ) Eating Disturbances

( ) Emotion Regulation ( ) Fatigue ( ) Trust/Relationship Issues OTHER_______________

SUICIDE RISK: Have you ever tried to harm yourself in the past? ( ) Yes ( ) No

Have you had any recent thoughts, or do you currently have any thoughts of suicide? ( ) Yes ( ) No

List all current medications and how often you take them/dosages.

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List any over the counter medications and supplements.

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Current/Past Major Medical Problems/Illnesses/Surgeries/Hospitalizations

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Menstruating ( ) Yes ( ) No Premenopausal ( ) Yes ( ) No Postmenopausal ( ) Yes ( ) No

Are you pregnant, or do you think you are pregnant? ( ) Yes ( ) No

Are you undergoing fertility treatment? ( ) Yes ( ) No

Are you undergoing any other gynecological treatment? ( ) Yes ( ) No